Nationwide $ervices, Inc.

Immediate Claim Placement Form

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Claim Placement Form


Please proceed with immediate collection on the account listed. We agree to notify you promptly of any payments received. We agree to pay your fees on any payments made from the date of assignment forward. We understand agency retains interest collected unless other arrangements are made.  We understand claims cancelled or withdrawn are subject to a fee.

Please complete as much information as possible so that we can help you to the fullest extent.

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Street Address
Name Of Contact
Phone Number
Total Due
Date of Invoice
Your Name
Your Company Name
Your Street Address
Your City
Your State
Your Zip
Your Phone Number
Your Fax Number
Your E-mail Address